Opioid Bills in the Senate: Focus on Medicare and OTPs

By Alison Knopf

“I don’t think there’s a single legislator who isn’t interested” in passing opioid bills, Mary Bono, former Republican Congresswoman from California, told AT Forum last month. The giant package from the House of Representatives—H.R. 6–SUPPORT for Patients and Communities Act—passed June 22 by a 396-14 vote. Provisions are now under consideration in four Senate committees.

Former Speaker Gingrich: “A National Crisis”

Bipartisan support doesn’t mean legislation is guaranteed to pass: lawmakers need to know how important the legislation is to their constituents. “This is a national crisis, and legislation has bipartisan support,” former Speaker Newt Gingrich told AT Forum last month. “Both ethically and politically, Congress has to pass a bill,” said Mr. Gingrich, who is also an advisor to Advocates for Opioid Recovery (AOR). “I think it will happen this year,” he added, “but it’s important for the community to keep the pressure on.”

On the Senate side, the Committee on Health, Education, Labor and Pensions (HELP) passed the Opioid Crisis Response Act of 2018 (S. 2680) in April. Three Senate committees, in addition to HELP, are considering opioid legislation: Judiciary, Finance, and Commerce. Finance has the provision of H.R. 6 that covers Medicare expansion for Opioid Treatment Programs (OTPs).

Key Legislation for OTPs: H.R. 6 

Passed in the House, now under consideration in the Senate, the bill to expand Medicare coverage is the most important legislation for OTPs, said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD).

“The issue that bears watching is keeping the focus on OTPs, and not just MAT [medication-assisted treatment]. The use of buprenorphine is good; the medication is effective; our concern has always been, what is the treatment itself?” he said.

For 10 years Mr. Parrino has worked on getting Medicare legislation passed. It has taken this long partly because changing Medicare payments to such an extent needed the approval of Congress. The Centers for Medicare and Medicaid Services (CMS)—lacks the authority to make the change.

CMS can add Medicare coverage under Part D, which covers drugs only, but not under Part B, which would cover services (including in a doctor’s office or in an OTP). A new category—the bundled rate for treatment in the OTP—needs approval by Congress. The House has already approved Medicare coverage of OTP services, including all three federally approved medications, under Part B, as part of H.R. 6. But pressure must be maintained in the Senate; it needs to upgrade the wording in its version to cover all patients, and not just as a demonstration project.

“I don’t want to go member by member,” said Ms. Bono, asked how she thought senators would line up behind provisions such as requiring Medicare to pay for OTP treatment. “But the notion of having access to medication-assisted treatment is widely accepted,” she told AT Forum.

Still, expanding Medicare coverage for OTPs “is a relatively new concept for Congress, something we had to look really hard at in Washington,” she added. Indeed, the House version of the Medicare bill goes further than the Senate version—at press time, the Senate version looked more like a demonstration project than full coverage.

 Summary of Key Bills

H.R. 6   SUPPORT for Patients and Communities Act Passed by the House Provisions under consideration in three Senate committees: Judiciary,  Commerce, and Finance; Finance has provision covering Medicare expansion for OTPs Full Title The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment [SUPPORT] for Patients and Communities Act H.R. 6082   Overdose Prevention and Patient Safety Act Passed by the House; under consideration in the Senate Would replace the protections of 42 CFR Part 2, HIPPA’s confidentiality regulation Under provision referred to Senate HELP Committee, treatment providers could release patient information without obtaining consent from the patient indicating to whom the information is being released S. 2680   Opioid Crisis Response Act of 2018 Passed by the Senate Committee on Health, Education, Labor and Pensions (HELP) Other Senate Committees Considering Opioid Legislation Judiciary, Finance, Commerce

August Recess Looms, Then Midterm Elections; Will the Senate Act? 

If the Senate doesn’t tackle opioid legislation by the August recess—shortened, because of the legislative workload—the delay could perhaps extend even past the midterm elections.

It’s more important to “get it right” than to rush it through, said Ms. Bono. “Before or after the elections—there’s a lot in play with this schedule.” Ahead are many nominations and appropriations, and a Supreme Court nomination—“always a huge heavy lift for the Senate,” she said. “In this contentious environment, it’s even more so.”

So, the opioid bills, despite having widespread bipartisan support, will “take a lot more effort” than lawmakers would like, said Ms. Bono.

Congress Takes a Leap Forward

The passage of H.R. 6 is an unprecedented leap forward, said Rep. Kevin Brady (R-Texas), chairman of the House Ways and Means committee, on the day the bill passed. “The impacts of the opioid crisis reach every community across the nation, and Congress took major action to fight back today.”

Eight committees in the House, including the Ways and Means committee, put forward bipartisan proposals to help the families and communities we represent,” said Congressman Brady, after the bill passed. “In particular, H.R. 6, the SUPPORT for Patients and Communities Act, puts in place many common-sense measures to reduce the unnecessary prescription of opioids, and to assist those who’ve become addicted.”

Kudos to the Committees

Congressman Brady mentioned the passage of over 70 pieces of bipartisan legislation within two weeks before the vote on H.R. 6. All “will improve addiction treatment, encourage pain management alternatives, enhance prescription monitoring programs, and crack down on foreign shipments of illicit drugs.”

The congressman applauded the House Ways and Means committee for its commitment in sending the proposals on to the Senate. “While we still have a long way to go, this legislation makes meaningful strides to help millions of Americans, and starts the recovery from this terrible epidemic.”

We asked Jesse A. Solis, deputy press secretary for the House Ways and Means committee, what he expected in the Senate. “We will have to defer to Senate leadership on timing,” he replied. “The House continues to stay engaged because the opioid crisis affects every district across the country. Our communities are counting on Congress to act, and that is what the House has done.

“This is a bipartisan issue that over eight Committees in the House have worked on, in this Congress alone. Our Members drafted these bills by listening to the concerns of their constituents, and from those fighting this battle at home, and we look forward to continue working with the Senate to ensure we send this important legislation to the President’s desk.”

Mark Parrino to Senate: “Kill” The Confidentiality Bill

The House of Representatives also passed the “Overdose Prevention and Patient Safety Act” (H.R. 6082). It would replace the protections of 42 CFR Part 2, the confidentiality regulation, with HIPAA; treatment providers would no longer need consent before releasing patient information. This provision was not folded into H.R. 6, and was referred to the Senate HELP committee. AATOD, the Legal Action Center, Faces & Voices of Recovery, and NAMA strongly support 42 CFR Part 2.

“I sent a letter to every chief of staff of every senator, telling them, ‘If the confidentiality bill comes over there, kill that bill,’” Mr. Parrino told AT Forum.

Educating Policymakers About OTPs

There is some concern that with all the money going to fight the opioid epidemic—the State Targeted Response (STR) grants and the State Opioid Response (SOR) grants from SAMHSA, for example—the infrastructure isn’t there to use it well. “Those of us in the addiction world have fought and fought and fought—for years—it’s really too bad that in all these years people didn’t invest in the infrastructure,” said Ms. Bono.

Few legislators are untouched by the epidemic, she said, but even so, they don’t know about OTPs. “These OTPs are in every community, they have a story to tell, they create jobs in the district,” she said. “OTPs need to get into the Congress and talk to their members about it, because it’s something people don’t really understand.”

In fact, AATOD met with people in 50 congressional offices in June. The big push, in which OTP executives from across the country visited 50 members of the House of Representatives and the Senate, focused on the Medicare bill. “AATOD and Mark [Parrino] have been working on getting Medicare coverage for OTPs for many years,” said Jason Kletter, PhD, president of Baymark Health Services. “This was a big hurdle, and now we have success in getting a bill passed on the House side.” The House version is “really well drafted,” he commented. Dr. Kletter credits AATOD with many years of diligence in getting support from lawmakers on Medicare expansion to OTPs: “You have to get so many people going in the same direction.”

A “Demonstration” Project—After Five Decades?

However, the current Senate version of the Medicare proposal is just a demonstration project. “They’re effectively saying, ‘Let’s try this out,’” said Dr. Kletter. “Our perspective is, we don’t need to try this out, there are five decades of rigorous science and millions of patient years of experience that demonstrate the efficacy of OTP services—so why would we do a demonstration project?”

Moreover, the demonstration project will cost $70 million to cover 2,000 Medicare beneficiaries, while adopting the policy as a full Medicare benefit, as in Senate bill 2875, will cost $243 million, according to the Congressional Budget Office, said Dr. Kletter. “If there are 300,000 current Medicare beneficiaries with OUD, that means we can do a    demonstration for $35,000 per beneficiary—or we can cover 300,000 people for $810 per beneficiary,” he said. “And the demonstration will postpone full implementation for at least five more years, while we are in the midst of an opioid epidemic.”

As Anne Woodbury, Executive Director of Advocates for Opioid Recovery, put it, “OTPs are the most studied and regulated of all recovery pathways.” So why is the Senate only looking at a demonstration project for the Medicare coverage? she asked. “They’re paying all this money to regulate the OTP industry, and now they’re going to do a demonstration project to see if it’s working? The House language is much better.”

Advocates for Opioid Recovery has a link that is easily used to send letters of support to Senators for H.R. 6. Go to: https://www.opioidrecovery.org/actnow/. “This is a great tool,” said Dr. Kletter. “All you have to do is enter your name; it sends the letter for you.”

Medicare Recipients With OUD: 300,000—and Counting

There are 300,000 people currently in Medicare with diagnosed opioid use disorder, said Dr. Kletter. They might be in OTPs, paying out of their own pocket. And other patients in OTPs are turning 65 and losing access to their coverage, because once 65 and eligible for Medicare, most are terminated from other insurance (see http://atforum.com/2017/12/medicare-reimbursement-otps-cited-briefing/).

“Congress has been fed information that says medication-assisted treatment is the right thing to do,” said Mr. Parrino. “But very few people recognize that the assisted part is the critical part. And Congress isn’t being told that DATA 2000 practices are primarily using the medication part.”

After the Hill visits in June, OTP executives now understand that endorsement of MAT does not mean endorsement of OTPs. And they worked to educate those 50 lawmakers on what OTPs are. “By virtue of having OTP directors speaking directly to Congress and their staff, we are educating them about what medication-assisted treatment is, and is not,” said Mr. Parrino.

Be Clear: This is About OTPs

Because the opioid overdose epidemic is a crisis, Congress wants to “do crisis things,” said Mr. Parrino. This is another reason it’s important to get the correct bills passed. “They get all excited; they are learning about methadone, buprenorphine, and Vivitrol,” he said. “But we say, ‘Wait a minute—you have to focus on the assisted part.’” The lawmakers and their staff are in “operation go mode,” he said. “We have to say, ‘Please be thoughtful.’”

But Mr. Parrino persists, and that’s one of the reasons the House Medicare bill is so well written.

“A lot of my colleagues are saying, ‘This is great; they’re all talking about medication- assisted treatment for opioid use disorder,’” he said. But advocates must be clear. Are they talking about OTPs? About OBOT [office-based opioid treatment] buprenorphine? About Vivitrol? About primary care with no “assisted” part at all? “You have to be clear when you advocate, or you’re selling them a bill of goods,” said Mr. Parrino. He added, “it’s not in the interests of some advocates to be clear.”

Indeed, everyone, including AOR, has their own interests. So, for OTPs and patients, it’s important to remember that Medicare coverage for treatment in an OTP comes first.

Mr. Parrino cited the landmark study by John Ball, PhD, the 1988 study that found that the characteristics of the treatment environment are more important than the characteristics of the patient in determining outcomes. If the program is set up in an organized, therapeutic way, patients will do well, the study found. “If the environment is chaotic, you will not be successful treating most patients,” said Mr. Parrino.

There is still work to be done in getting lawmakers to this point. “Most people don’t understand the clinical aspects of treating the illness itself,” he said. “They think, ‘let’s make buprenorphine available to anyone, and let’s not worry about any subsequent ramifications.’”

Methadone? Yes, Methadone!

It’s also important to have patients involved in advocacy, said Ms. Woodbury. “We have a survivors’ council,” she told AT Forum—these are people in active recovery, or family members of people in active recovery. “We’re activating them to contact their members of Congress in both chambers,” she said. “We’re also trying to drum up grass roots support.

One problem is, no matter how strongly a lawmaker may think he or she supports medication-assisted treatment, when it comes to methadone, myths and misperceptions abound, she said. “The more we can bring real people to them, and show them that they need real services, the better.”

These services include medication, behavioral counseling, telemedicine, and Medicare coverage for OTPs, all of which can be well described by patients and advocates. “We still have a lot of misperceptions by many members of Congress who maybe haven’t had a personal exposure to opioid addiction, or whose families haven’t been affected,” she said.

Some lawmakers look askance at methadone when it is presented to them as part of the toolkit for treating opioid use disorders, Ms. Woodbury reported. “’Really, methadone, that’s what you want me to go with?’ they ask.” One good response is to point out that these patients are 50% less likely to die from an overdose than patients not in treatment, she said. But of course, it’s more than that, she added—not only do patients not die, they go on to have productive lives.

In policy settings, a common catch phrase is “Don’t make the perfect be the enemy of the good.” Ms. Bono cited this comment in terms of MAT, noting that it’s helpful in convincing some lawmakers to “believe in” methadone. “This is a lifesaving medication,” she told AT Forum. “It allows people to live their lives.”

Members of Congress always benefit when they see patients who are in treatment with the medication, she said. “Abstinence is what everybody aspires to;” even some patients on methadone think that one day they may taper off. “I’m asthmatic; in a perfect world do I wish I didn’t have to carry an inhaler around with me?” she asked. But of course, asthma is not the same as addiction. “I don’t feel stigmatized” the way many methadone patients do, she said. “But the point is, folks who are in treatment can live productive lives, can hold down a job, can have a family.”

The choice between methadone, buprenorphine, and naltrexone is one to be made by the patient and physician, but all three are not necessarily for lifetime use, she said–although results are much better if they stay in treatment, research has shown. “If someone wants to taper off, if their physician says they can, then absolutely they can,” said Ms. Bono.

Getting it Done, and Done Right

“I’m hoping this gets done before the end of the year, even if it’s in a lame duck session,” said Ms. Woodbury. “The main thing is to keep the pressure on and to keep the community where it needs to be to step up the activation, in terms of the recovery side of the equation,” she said.

And like Ms. Bono, she stressed the importance of making sure that the best provisions—such as Medicare coverage for OTPs—are included.

Something will pass this year, or Republicans will not look good.

It just has to be the right piece of legislation.